Fred Bauermeister is executive director of the Free Clinic of Simi Valley, a health care provider to undocumented immigrants for years. (Lauren Whaley/CHCF Center for Health Reporting)

Clinic director Fred Bauermeister has watched them pass through his doors for decades: chronically ill, uninsured men, women and children, who have delayed medical care because they are in the country illegally.

Now, immigration reform may bring health benefits to millions of formerly undocumented people — although there may still be a years-long wait after they attain legal residency.

But first — the immigration reform piece: a bandwagon of endorsements last week by Congressional Republicans have aligned with vows by President Obama and Senate Democrats to establish comprehensive immigration reform. A road to citizenship for people who entered the country illegally seems more assured by the day, but what is less clear is how the health care landscape of California, and the nation, would also change.

Would California’s estimated 2.5 million undocumented immigrants become eligible for health benefits? How would an already burdened health care system absorb them?

“We’re very interested — and very concerned – with how this is all going to work out,” said Bauermeister, executive director of the Free Clinic of Simi Valley, a California provider that seeks to keep immigrants out of expensive modes of care like the emergency room.

Obama’s commitment to move an estimated 11 million undocumented immigrants nationally “out of the shadows” would not end there. Under current law, it would also slowly open the door for them to qualify for public programs, including the health care overhaul’s massive coverage expansions.

Obama’s plan would have immigrants wait at least eight years before they qualify for health benefits. A Congressional plan spearheaded by Republican senators Marco Rubio and John McCain pushes the wait to at least 10 years.

Some experts believe both scenarios would create an interim period in which even wider gaps will develop between the haves and have-nots of health care.

If health reform works as intended, there will not only be a boost in the number of new people covered, but a steady improvement in their health. Meanwhile, undocumented immigrants sit on the sidelines for, give or take, at least a decade.

“We’re going to create a two-tiered system of health, as well as perpetuate disparities in health,” said Ignatious Bau, a San Francisco-based health policy consultant whose clients include insurance giant Kaiser Permanente.

“People who are in the system are going to get better quality and efficiency,” said Bau. “But [undocumented] people who aren’t in the system are going to go to the ER.”

The haves, incidentally, will continue to be stuck with the bill for the health care have-nots, Bau said.

One is the Medicaid safety net, called Medi-Cal in California, from which undocumented immigrants are generally excluded.

The other is the government-subsidized insurance marketplace, Covered California, designed to help consumers find affordable health plans of their own choosing. Undocumented immigrants cannot participate in Covered California either.

The exclusions frustrate many health experts. They say that including currently ineligible immigrants in reform would slash the ranks of the uninsured.

According to a 2011 study by the UCLA Center for Health Policy Research, 84 percent of California’s 7 million uninsured will qualify for health reform coverage as it currently stands.

If undocumented immigrants were added to the health reform mix, 100 percent of the state’s uninsured would then be eligible for some form of coverage. Still, experts say, because of language barriers and personal choice, it is unlikely every qualified immigrant would apply.

Nationally, the Congressional Budget Office reported in 2010 that more than 90 percent of U.S. residents could eventually be insured with the boost provided by health reform, leaving about 23 million uncovered. If undocumented immigrants were granted coverage, the uninsured would be slashed by an additional third.

Studies like Health Care Reform in Transition, in the Journal of the American Medical Association, find the larger the population in an insurance pool, the more stable the premiums.

“The healthy subsidize the sick,” the 2010 study found.

Scholars also cite studies showing that immigrants are generally younger, and healthier, than the U.S.-born population when they first arrive. As they stay in the United States longer, their health begins to decline and look like that of their U.S.-born counterparts, studies find.

Nevertheless, Obama cites the Personal Responsibility and Work Opportunity Act of 1996, which bans green card holders from public benefits for five years, and his own ideas, as the timetable for immigrant access to health reform.

According to a leaked copy of the President’s proposal, undocumented immigrants must get in the “back of the line” and petition to become a “Lawful Prospective Immigrant.” They must hold that newly created status for at least eight years.

From there, they can be declared a “Legal Permanent Resident” with a green card. But they must hold the green card for at least five years to qualify for public health benefits including the expanded version of Medicaid created by reform.

“If everybody else is covered,” Bauermeister said, “then the ones who aren’t are going to be our patients.”

If you want to keep low CBO’s cost estimates of rewarding millions of illegal immigrants with legal residency, advocates for that need to at least say they will exclude them from government benefits and have that used as the basis for calculating the usual 10-year window of CBO estimates. I think it would be useful to have those cost estimates also done showing the costs that would accrue if they were given full access to such benefits and, for those of us who care about reality, an estimate of the constant dollar net fiscal impact over their lifetimes. The lion’s share of government benefits go to the elderly, and excluding the impact of mass amnesty on that cost to government is a form of willful blindness.

Concerned Citizen

There are alternative being proposed such as AB 175 which are practical and could prove very vital in years down the road. This approach was proposed back in 2001/02 with legislation by Assemblyman Dean Flores (AB 883) that was developed by community health centers serving farm worker communities and while it passed the Assembly it died in the Senate Health Committee and not because of opposition from the “right” or cost concerns. It had the support from the California Farm Bureau and perhaps that is why it was left to die because it had support of “growers”. Bottom line there are thing that can and should be done but as the article states it appears that “established groups” will only support their approach and not others that offer a real concrete option for uncovered workers. These workers are in need of as many options as possible. Otherwise all the talk about their plight is just well intentioned noise!

Author

Lisa Aliferis

Lisa Aliferis is the founding editor of KQED's State of Health blog. Since 2011, she's been writing and editing stories for the site. Before taking up blogging, she toiled for many years (more than we can count) producing health stories for television, including Dateline NBC and San Francisco's CBS affiliate, KPIX-TV. She also wrote up a handy guide to the Affordable Care Act, especially for Californians. Her work has been honored for many awards. Most recently she was a finalist for "Best Topical Reporting" from the Online News Association. You can follow her on Twitter: @laliferis

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California faces health care challenges seen across the country. At a time of intense focus on reform, "State of Health" explores these issues and more, bringing you stories of challenge and change in the Golden State. The blog is edited by Lisa Aliferis.